Amber Watters, MD, on anesthesia in external cephalic version for breech presentation

A recent statement from the American Society of Anesthesiologists (ASA) encourages obstetric units to build a formal process for offering external cephalic version (ECV) with neuraxial anesthesia as a key component, an approach that aligns with efforts to reduce primary cesarean delivery, according to Amber Watters, MD, MS, Assistant Professor of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, and Chief of Obstetrics, Northwestern Medicine.

The ASA statement, developed by its Committee on Obstetric Anesthesia and approved October 15, 2025, noted that ACOG recommends ECV for breech presentation at or after 37 weeks' gestation in the absence of a contraindication to vaginal birth. Breech presentation occurs in 3% to 4% of term pregnancies according to the ASA, and neuraxial anesthesia increases the success rate of ECV (RR 1.37; 95% CI, 1.19-1.58) and of vaginal birth (RR 1.23; 95% CI, 1.03-1.47).

Watters framed the statement as reinforcing established obstetric priorities.

“The ASA statement is really intended to encourage obstetric units to develop a process for offering external cephalic version to patients and including neuraxial anesthesia as a key component of that process so that patients will have that available as an opportunity for them,” she said.

She tied that process to cesarean prevention.

“Offering external cephalic version to all patients presenting with malpresentation is one of the best tools we have to prevent primary cesarean delivery. And we know that preventing that first C-section is really key to maternal health long term,” Watters said.

The value of anesthesia collaboration

Watters emphasized the role of the anesthesia team in managing hypotension, a recognized effect of neuraxial technique. Per the ASA statement, maternal hypotension should be aggressively prevented and managed with intravenous fluids and vasopressors as needed.

“Anesthesia colleagues are used to managing hypotension, and so they have the medications at hand to be able to respond, and they're right there throughout,” she said. “There are things you can do in advance of neuraxial anesthesia to try to prevent hypotension... but I think really that immediate management of it as it occurs by your expert colleague at the bedside is a key piece of your process.”

Treating ECV as a scheduled procedure

Watters recommended structuring ECV like a scheduled procedure to coordinate teams, noting that not all labor and delivery units have anesthesia in-house at all times.

“Scheduling the procedure as such will allow you to ensure that you have designated experts for the anesthetic portion of it, as well as your obstetric people,” she said, adding that a time-out at the time of the procedure helps align all personnel on the plan. The ASA statement similarly recommends preprocedure notification of an anesthesia professional and a multidisciplinary huddle to identify team members and management strategies.

Reference:

Statement on Anesthesia Management and Support for External Cephalic Version. American Society of Anesthesiologists. Committee on Obstetric Anesthesia. Approved October 15, 2025. Accessed September 8, 2026. https://www.asahq.org/standards-and-practice-parameters/statement-on-anesthesia-management-and-support-for-external-cephalic-version